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The social determinants of health, according to WHO (2004), state that the social conditions in which people live greatly affect their chances of being healthy. For the purpose of this assignment, this writer has chosen to critically analyse how the following determinants of health; (1) Social Exclusion (2) Community Support, and Employment, impact the lives and health of people living with a mental health condition. This student will then attempt to critically discuss the political actions that have been taken to address these inequities as experienced by this social group.

Raphael (2008) and WHO (2008) state that social determinants of health are the socio-economic circumstances which affect the health of individuals, communities and jurisdictions as a whole and the conditions in which people are born, grow, live work and age, including the health system.

The Commission on Social Determinants of Health (2009) deliver three recommendations, (1) to improve daily living conditions, (2) to tackle the inequitable distribution of power, money and resources, and (3) to measure and understand the problem and assess the impact of action, in order to improve health services for all. The American Psychology Association (APA) and WHO define mental health as; A state of emotional and psychological well-being in which an individual is able to use his or her cognitive and emotional capabilities, function in society, and meet the ordinary demands of everyday life.

2. Social Determinants of Mental Health and Their Consequences:

While medical intervention can prolong life and improve outcomes after serious illnesses, what is more important for the health of the population as a whole, are the combined social and economic factors that make people ill and in need of medical care in the first place. (WHO, 2003).

2.1 Social Exclusion:

Social exclusion is a vicious circle that deepens the predicament that people with a mental illness face. When a person is treated as less than equal, or excluded from society due to their illness, they will become even more psychologically damaged. This in turn will also affect their physical health and their perceived ability to function as a ‘normal’ member of society. Some forms of social exclusion these people face are discrimination, stigmatisation, hostility and unemployment. Access to education or training programmes is hindered. Men and women that may have been institutionalised at some point, such as in children’s homes, psychiatric units and prison services are especially vulnerable to social exclusion.

Supportive relationships makes people feel cared for, loved, esteemed and valued. These are powerful factors for a positive impact on mental health. People who do not get enough social and emotional support from those around them are more likely to experience mental and physical health difficulties. The quality of social relationships, the existence of trust and mutual respect help to protect a person’s sense of self. Some experiments have even found that good social relations can reduce the physiological effects of stress on the body. This is important in relation to cardiovascular and immune system function, which are both directly affected when the stress-response ‘fight or flight’ is constantly activated.

Unemployment only serves to reinforce anxiety and depression in the mentally ill. Financial worries, combined with feelings of worthlessness and inability to contribute to society increases stress, worry and inability to cope. These insecurities and frustrations can affect the relationships with friends and family members, further isolating them from the social network that they are reliant on in order to stay well.

Before the 1945 Mental Treatment Act, no policies had been implemented since Victorian times, which saw ‘Fools, Lunatics and the Mad’ incarcerated in penal institutions or asylums. With this Act and the establishment of the Irish Free State, the nomenclature associated with insanity and the insane began to change, albeit gradually. ‘Asylums’ became hospitals, ‘Insanity’ was renamed Mental Illness and ‘Lunatics’ were now called Patients. A shift towards a more psychodynamic approach to recovery began to emerge.

The first comprehensive report specifically addressing the needs of the mentally ill was the Commission of Inquiry on Mental Illness in 1961. The final report was released in 1966. Segregation from society, separation from other patients and staff members and classification according to social status and illness was still prevalent

In relation to the 1945 Mental Treatment Act, Irish medical legal expert Deirdre Madden questions the definition of ‘competence’, regarding a person’s capacity to understand, use and weigh consequences of their decisions. Outside the Mental Health Act 2001, there is no legal assessment in Ireland for determining competence. [Donnelly 2002:50]. Van Dokkum (2005) states the medical profession would use ‘a status approach’ – which is essentially ‘a label and be done with it’ approach rather than a fairer ‘relative capacity approach’.

The Mental Health Commission acknowledge that some of the recommendations in this policy have been implemented, such as child and adolescent services, the finalising of mental health catchment areas and the progress in the appointment of leadership structures both nationally and regionally.

However, the inspector of Mental Health Services has been critical of the HSE to appoint a Mental Health Directorate, arguing that a ‘well-run, accountable and partly autonomous division would be budget beneficial and improve outcomes’. This report goes on to state that a change is required in how mental health services are delivered and in how we think about mental health itself. Mental health services should focus on the possibility of recovery.

In 2009, this group published a report entitled ‘Third Anniversary of AVision for Change; Late for a Very Important Date’. They state that reform has been painfully slow and despite statements of support from Government and the HSE, basic systems to promote reform are not in place, targets have not been met and development funding has all but ceased.

Irelands mental health expenditure has dropped from 13% of the national health budget in 1984 to 7.34% to date. The economic costs of mental health problems are considerably large, most of these costs being encurred through loss of jobs and absence from work due to ill health. They state that cutting the health budget in relation to mental health provision is short-sighted as the cost of providing preventative and screening services is modest in comparison to the socio-economic costs as listed above.

There have been many positive campaigns in recent years to highlight mental health issues. However, according to Mental Health Ireland, mental health promotion remains the most underdeveloped area of health promotion. The WHO states that strengthening mental health promotion is necessary to achieve real reform. Some of these positive health campaigns include ‘Beat the Blues – Aware’, ‘Mental Health Matters – Mental Health Ireland’, ‘Reach Out – National Strategy on Suicide Prevention’ and ‘Please Talk’ campaigns run by The Samaritans.

Although many inequities of mental health service provision have been addressed with the implementation of government policies in recent years, we have a long way to go before social integration and inequalities are recognised. A very significant step forward has been the establishment of the Mental Health Commission. [McAuliffe et al]. The biggest challenge will be to establish social support networks in relation to mental health. [Kelly 2003]. If mental health becomes more of an everyday issue, affecting us all, then the stigma surrounding it will be alleviated.

While Irish society faces many economic challenges in the future, establishing a more aware, mentally healthier community will provide better coping mechanisms for those affected by these issues.

Moving away from the current medical model of psychiatry and drug-based therapies to a more holistic ‘all-inclusive’ biopsychosocial approach is a key element in addressing inequities relating to mental health care. Sociology shows how mental illness is socially patterned, which suggests the importance of the social environment to mental well-being. Implementation of the community care model has proven to be a slow process and its’ implementation needs to be critically readdressed to recognise the needs of those with chronic mental illness and not just of those who are acutely ill. [Hyde et al (2005)].

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